Student Trip Travel - Pennington Biomedical Research Center

Completion of this form is not a guarantee of coverage. Travel must meet all requirements outlined by the insurance policy. If you have any questions or would like to discuss program coverage please contact the Office of Risk Management.

Campus

PBRC

Name of Organization/Department*

(e.g. School of Mass Communication, College of Engineering, etc.)

Destination*

(e.g. Bluebonnet Swamp)

City*

State*

Select or enter value

Mode of Travel*

Select or enter value

Who will be driving?*

Select

Driver's name*

Drivers Contact Information*

Date of Departure*

Date of Return*

Number of LSU Students Traveling*

(Please insert a number, no text characters)

Contact Person

Name*

Email*

Phone*

(Use xxx-xxx-xxxx format)

Other Participants Traveling*

Will you be traveling with non-LSU students or employees?

Yes

Number of Non-LSU Students or Non-LSU Employees Traveling*

Please only enter a value greater than 0 if the person(s) traveling are not an LSU student or LSU Employee. No other text characters are needed.

Account Number

If coverage is being provided to anyone other than LSU Students please include an account number that will be billed at ten cents per person per day at the end of each semester. If Account is grant funded, please respond to your confirmation e-mail with the date that all charges should be processed.

Data Authorization*

I authorize that all information provided on this form, including any and all personal, financial and academic data may be shared with the LSU Risk Management and university insurance carriers and vendors. This data will be securely retained indefinitely. To learn more about privacy at LSU, please see the LSU Privacy Statement.

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